Inadequate hospital care for learning disabled
Failures in basic care, pain assessment, missed examinations, and escalation for learning-disabled adults in hospitals.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
HSSIB recommendation
100match
Caring for adults with a learning disability in acute hospitals
HSSIB recommends that the NHS England commissions the development and dissemination of guidance on the practical assessment of the mental capacity of people with a learning disability in acute hospitals. This is to ensure that appropriate decisions are made about the person’s care.
Matched on
terms: care, hospital, learning
PFD report
99match
David Lodge
The coroner identified inadequate pain assessment for non-verbal patients and insufficient basic chest examinations for learning disabled adults at risk of pneumonia in the emergency department, alongside inadequate escalation of high NEWS2 scores.
Matched on
terms: disabled, inadequate, learning
CQC action
90match
Sunderland Royal Hospital
The trust must ensure staff undertake assessments for patients who have a learning disability, where care needs are assessed and planned to meet their individual needs.
Matched on
terms: care, hospital, learning
CQC action
90match
South Tyneside District Hospital
The trust must ensure staff undertake assessments for patients who have a learning disability, where care needs are assessed and planned to meet their individual needs.
Matched on
terms: care, hospital, learning
CQC action
90match
Ellesmere Port Hospital
The trust must ensure staff undertake thorough assessments for patients who have a learning disability, care needs are assessed and planned to meet their individual needs.
Matched on
terms: care, hospital, learning
PFD report
89match
Stephen Dulling
The coroner identified inadequate assessment and practical advice during a crisis call by Tees Esk and Wear Valley NHS FT. There were also multiple lapses in basic nursing care at York & Scarborough Teaching Hospitals NHS FT, including nutritional management and a delayed response to choking.
Matched on
terms: care, hospital, inadequate
CQC action
86match
Kettering General Hospital
The servicemust ensure the needs of patients with a learning disability or autistic people are regularly assessed and they are provided with person centred care.
Matched on
terms: care, hospital, learning
CQC action
86match
Fleetwood Hospital
The trust should consider including mental health, learning disability and autism needs in their model for identifying patients for supportive and palliative care.
Matched on
terms: care, hospital, learning
LGO / SPSO decision
86match
23-013-609b - Royal Free London NHS Foundation Trust - North Middlesex Hospital (23 013 609b)
Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found there were avoidable delays in the discharge process,...
Matched on
terms: care, hospital, learning
LGO / SPSO decision
86match
23-013-609a - Royal Free London NHS Foundation Trust - North Middlesex Hospital (23 013 609a)
Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found there were avoidable delays in the discharge process,...
Matched on
terms: care, hospital, learning
PFD report
81match
Rose Harfleet
The coroner identified insufficient guidance for managing profoundly disabled children in hospital, inadequate parental consultation leading to poor clinical decisions, staff not acting on observations, and the absence of a Learning Disability Liaison Nurse.
Matched on
terms: disabled, hospital, inadequate, learning
Committee recommendation
81match
#55 - Third Report - Coronavirus: lessons learned to date
People with learning disabilities have experienced significantly higher death rates from covid-19 than the country as a whole. Deaths have been especially high among younger adults with learning disabilities. Initial research suggests that people with learning disabilities entered the pandemic from a position of heightened vulnerability because of existing comorbidities. This was compounded by particular barriers to accessing...
Matched on
terms: care, hospital, learning
Committee recommendation
81match
#55 - Sixth Report - Coronavirus: lessons learned to date
People with learning disabilities have experienced significantly higher death rates from covid-19 than the country as a whole. Deaths have been especially high among younger adults with learning disabilities. Initial research suggests that people with learning disabilities entered the pandemic from a position of heightened vulnerability because of existing comorbidities. This was compounded by particular barriers to accessing...
Matched on
terms: care, hospital, learning
Scottish FAI
81match
James Maughland
Hospitals (other than psychiatric hospitals) should review how they deal with the admission of patients with learning disability or mental illness and devise a protocol for identifying such patients and to ensure that there is proper communication with them not only on admission but throughout their stay in such hospitals. Where there is a patient in a general...
Matched on
terms: care, disabled, hospital, learning
CQC enforcement action
77match
Warning Notice: Tees, Esk and Wear Valleys NHS Foundation Trust
The Care Quality Commission (CQC) conducted an inspection of inpatient wards for people with a learning disability or autistic people at Lanchester Road Hospital and Bankfields Court, operated by Tees, Esk and Wear Valleys NHS Foundation Trust. Following the inspection, CQC told the trust to make improvements due to a significant deterioration in standards of care, concerns about...
Matched on
terms: care, hospital, inadequate, learning
CQC enforcement action
77match
Warning Notice: Lincolnshire Partnership NHS Foundation Trust
The Care Quality Commission told Lincolnshire Partnership NHS Foundation Trust that it must take action to improve the care of those accessing its specialist mental health and learning disability services. Reports identified areas for improvement including the safety and suitability of hospital premises, care and welfare of people, cleanliness and infection control, staffing, respecting and involving people, and...
Matched on
terms: care, hospital, learning
Committee recommendation
77match
#19 - Fifth Report - The treatment of autistic people and people with learning disabilities
In recent years there have been too many incidences of autistic people and people with learning disabilities dying in inpatient settings. Families and friends have too often had to go to extreme and difficult lengths to have independent reviews into such deaths. Of even greater concern is that in some cases, the poor treatment of autistic people and...
Matched on
terms: care, hospital, learning
PHSO casework decision
76match
P-003645 - Barnsley Hospital NHS Foundation Trust
Ms G alleged her mother received inadequate basic nursing care, including cancelled procedures, delayed medication, and poor communication, leading to an undignified end of life.
Matched on
terms: care, hospital, inadequate
CQC action
74match
St Richard's Hospital
The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, dementia and autism.
Matched on
terms: hospital, learning
CQC action
74match
Scarborough Hospital
The trust must fully investigate and seek to learn from the death of a person with a learning disability or autistic people including seeking LeDeR reviews.
Matched on
terms: hospital, learning
CQC action
74match
Salford Royal Hospital
The service should consider developing a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism or a learning disability.
Matched on
terms: hospital, learning
CQC action
74match
Royal Sussex County Hospital
The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, dementia and autism.
Matched on
terms: hospital, learning
CQC action
74match
Poole Hospital
Consider how to link the more specific strategies, such as those relating to dementia and learning disabilities either to the main strategy, or into a framework which monitors their progress and documents assurance and success. This was of specific concern as the trust did not have a specialist lead nurse for learning disabilities and did not provide dementia...
Matched on
terms: hospital, learning
MNSI report
74match
Safety spotlight: Mothers with a learning disability
Safety spotlight on the care of mothers with a learning disability in maternity services.
Matched on
terms: care, learning
PFD report
73match
Mohammed Chaudhury
The coroner identified concerns regarding the development and deterioration of pressure sores due to inadequate nursing care, including a failure to turn patients regularly, missing care plans, and inconsistent Waterlow scoring. Additionally, nursing rotas were unavailable, understaffing was reported, and the safety of current staffing levels for high-dependency patients could not be confirmed.
Matched on
terms: care, inadequate
PFD report
73match
Myles Scriven
The coroner noted GPs had a superficial understanding of regulatory requirements and practicalities for patients with Learning Disabilities and Autism, leading to inadequate adjustments and poor management of the Learning Disabilities Register. Concerns were also raised about the failure to properly record numeric observations and undertake a rigorous internal review for learning.
Matched on
terms: inadequate, learning
Committee recommendation
73match
#12 - Fifth Report - The treatment of autistic people and people with learning disabilities
We recommend that, in addition to the implementation of the Mental Health Units (Use of Force Act) (i.e. ‘Seni’s Law’), all Assessment and Treatment Units (ATUs) are closed within two years and replaced with person-centred services that are: i) designed for easy discharge as well as easy admission; ii) physically designed and maintained to meet the needs of...
Matched on
terms: care, learning
Committee recommendation
72match
#9 - Fourth report: Unequal impact? Coronavirus, disability and access to services: full Report
Prior to the pandemic, people with learning disabilities experienced health inequalities and faced difficulties accessing healthcare and receiving accurate diagnoses and effective treatments. They had increased risks of dying from a range of illnesses, including respiratory infections. These problems have been exacerbated by coronavirus, to which, emerging data suggest, people with learning disabilities may be disproportionately susceptible. It...
Matched on
terms: care, disabled, learning
Committee recommendation
72match
#9 - Fifth Report - The treatment of autistic people and people with learning disabilities
Furthermore, we recommend that autistic people and people with learning disabilities should never be admitted to an inpatient facilities that has received an “inadequate” rating from the Care Quality Commission (CQC). The Department for Health & Social Care must bring forward measures to ensure that service commissioners can no longer buy services from settings that have been rated...
Matched on
terms: care, inadequate, learning
PHSO casework decision
72match
P-003666 - Great Western Hospitals NHS Foundation Trust
Mr F complained staff gave his father poor nutrition/fluids, inadequate mouthcare, left him without oxygen, and administered allergic antibiotics, which he believes led to his father's avoidable death.
Matched on
terms: care, hospital, inadequate
PHSO casework decision
72match
P-004140 - Oxford University Hospitals NHS Foundation Trust
Miss A complained about her daughter's inadequate aftercare post-transplant, including insufficient monitoring and placement outside intensive care, leading to cardiac arrest and death.
Matched on
terms: care, hospital, inadequate
PHSO casework decision
72match
P-004640 - The Hillingdon Hospitals NHS Foundation Trust
Miss B complained about inadequate care for her mother, an unwitnessed fall, poor nursing, delayed escalation, and poor communication during admission. She also cited poor complaint handling.
Matched on
terms: care, hospital, inadequate
PFD report
69match
Julie Taylor
The coroner noted the absence of reasonable adjustment care plans in emergency settings and a lack of formal best interests meetings for key decisions. Concerns were also raised about insufficient inter-agency communication and the limited availability of acute learning disability beds.
Matched on
terms: care, learning
PFD report
69match
Joseph Maunick
The report highlights a national shortage of appropriate care placements and insufficient hospital resources, which meant a patient requiring constant supervision for cognitive impairment could not receive adequate care in an Emergency Department, contributing to a fall.
Matched on
terms: care, hospital
PFD report
69match
Pamela Singh
The coroner noted the absence of a specific practice tool in Wales for family and care staff to recognise and escalate signs of acute deterioration in people with learning disabilities. This lack contributes to avoidable deaths from conditions such as pneumonia, despite recommendations to adopt such tools.
Matched on
terms: care, learning
PFD report
69match
Jacqueline Aarons
The coroner raised concerns about the need for a lower threshold for hospital admission for patients with learning disabilities, requiring face-to-face doctor consultations. Post-consultation, written instructions including safety netting advice should be provided in an accessible format for non-medically trained staff.
Matched on
terms: hospital, learning
Committee recommendation
69match
#11 - Fifth Report - The treatment of autistic people and people with learning disabilities
Inpatient facilities do not consistently meet the needs of autistic people and people with learning disabilities and too often this is because of factors such as the unnecessary use of restrictive practices; inpatient facilities being unable to accommodate individuals’ needs to avoid sensory overload; and the distance inpatient facilities are from individuals’ homes.
Matched on
terms: care, learning
Committee recommendation
69match
#5 - Fifth Report - The treatment of autistic people and people with learning disabilities
While we welcome the vision set out by Helen Whately MP (Minister of State, Department of Health & Social Care), we believe this is a matter of delivery and The treatment of autistic people and people with learning disabilities 39 not a matter for further review. At present, the work and output of The Building the Right Delivery...
Matched on
terms: care, learning
Committee recommendation
69match
#1 - Fifth Report - The treatment of autistic people and people with learning disabilities
Autistic people and people with learning disabilities have the right to live independent, free and fulfilled lives in the community and it is an unacceptable violation of their human rights to deny them the chance to do so. It is also more expensive to detain autistic people and people with learning disabilities in inpatient settings and this takes...
Matched on
terms: care, learning
CQC action
69match
Worthing Hospital
The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, dementia and autism.
Matched on
terms: hospital, learning
CQC action
69match
Russells Hall Hospital
The trust should continue to review and identify if their training meets the statutory learning disability and autism training requirements.
Matched on
terms: hospital, learning
CQC action
69match
Fairfield General Hospital
The service should consider developing a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism or a learning disability.
Matched on
terms: hospital, learning
PPO recommendation
69match
The Head of Healthcare
The Head of Healthcare should ensure that all prisoners with learning disabilities are clearly recorded, staff receive relevant learning disability training and follow NHSE/I guidance for prisoners with learning disabilities.
Matched on
terms: care, learning
LGO / SPSO decision
69match
NIPSO-201912943 - Belfast Health and Social Care Trust
The sister of a man with Downs Syndrome has received an apology from the Belfast Trust following our investigation into his treatment in Belfast City Hospital.
Matched on
terms: care, hospital
GIRFT recommendation
69match
Children and Young People's Mental Health Services
The additional needs and reasonable adjustments for young people with autism and/or learning disabilities, who are experiencing a mental health crisis, must be identified and managed in all settings. Services must ensure that: a There is effective and high-quality training for staff in autism. b As already indicated within the Department of Health Building Notes, outpatient and inpatient...
Matched on
terms: care, learning
Committee recommendation
68match
#4 - Fifth Report - The treatment of autistic people and people with learning disabilities
Since the Winterbourne View scandal, over 10 years ago, successive governments have committed to reducing the number of autistic people and people with learning disabilities in inpatient settings and prioritising community support for these individuals. However, missed and delayed policy targets suggest a more radical approach to unlocking funding for community provision is urgently needed. Too often autistic...
Matched on
terms: care, learning
PFD report
65match
Juliet Saunders
The coroner identified issues with insufficient supervision of junior doctors and poor medical record keeping within the emergency department. These factors contributed to diagnostic overshadowing, a failure to diagnose an acute condition, and inadequate escalation of complex cases, alongside concerns about patient transfer procedures and safety-netting advice.
Matched on
terms: inadequate
Committee recommendation
65match
#8 - 3rd Report - Legislative Scrutiny: Mental Health Bill
The detention of autistic people and people with learning disabilities under the MHA is a significant human rights concern. Detention in the absence of individualised, therapeutic treatment risks violating the Article 5 ECHR right to liberty and may even result in degrading treatment contrary to Article 3 ECHR. We welcome the Bill’s change in the threshold for detention,...
Matched on
terms: care, learning
HSSIB recommendation
65match
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that NHSX develops a standardised care passport, which should include sections to support patients with autism, learning disabilities or learning difficulties.
Matched on
terms: care, learning
CQC action
65match
Wavertree Bungalow
We recommend the provider assess the service using the principles of Right Support, Right Care, Right Culture, the CQC's guidance when providing support for autistic people and people with a learning disability.
Matched on
terms: care, learning